Holistic 3209 KSU Final Exam

What is the average normal amount for fluid intake and fluid output?

~2600 mL/day

What are some causes or risks for hypovolemia?

Diarrhea, vomiting, polyuria, losses through wounds, impaired swallowing, anorexia

What are some causes or risks for hypervolemia?

Heart failure, renal failure, liver cirrhosis, excess IV fluid intake, excess Na ingestion

What level of Na signals hyponatremia?

Less than 135 -> Less than 115 is emergency!

What are some nursing interventions for hyponatremia?

Hypertonic IV solutions

Limit fluid intake

Encourage food high in sodium

What serum Na level signals hypernatremia?

Greater than 145

What are some signs of hypernatremia?

Thirst

Red, dry, swollen tongue

Muscle weakness

A patient receiving Digoxin should be closely monitored for what electrolyte imbalance?

hypokalemia

What are some risk factors for hypocalcemia?

Removal of parathyroid glands

Decreased Vitamin D

What are some risk factors for hypercalcemia?

Immobilization

Hyperparathyroidism

Bone malignancy

What lab tests should be done to measure electrolyte balance?

Serum electrolytes

CBC

BMP (BUN, creatinine, etc.)

Urinalysis

ABGs

The nurse is assessing I/Os on a patient and notices a significant imbalance. What should the nurse do?

Call the doctor

What is the expected urine output per hour in an adult?

30 ml/hour

What are some examples of isotonic fluids?

0.9% NaCl (normal saline)

Lactated Ringers

D5W

What are some examples of hypotonic fluids?

0.45% NaCl

0.33% NaCl

What are some examples of hypertonic fluids?

D5NS

D5 1/2 NS

D10W

When evaluating outcomes in a nursing care plan, if the desired outcomes are NOT achieved, what should the nurse do first?

Explore the reasons why desired outcome was not achieved before modifying care plan

What are some chemical buffers in the body?

HCO3 and H2CO3

What mechanism of pH regulation in the body is the longest lasting?

Kidney regulation

What mechanism of pH regulation in the body is the strongest?

Respiratory

Is arterial blood or venous blood a better representation of gas exchange and pH?

Arterial

Euthanasia

"good dying"

Active Euthanasia

Taking specific action to cause a patient's death such as lethal dose

Passive Euthanasia

Withdrawing treatment to cause patient's death

Assisted Suicide

Providing patients the means to cause their own death *Unethical*

Hospice care is covered by Medicare under what stipulations?

Less than 6 mo. life expectancy

Must show evidence of decline

Must forego curative measures and transfer to comfort measures

Palliative care

Improving quality of life through aggressive management of symptoms

Hospice vs. Palliative care differences

Hospice -> No cures, only comfort measures. Has a time limit for life expectancy and is covered by Medicare.

Palliative -> Aggressive management of symptoms in hopes of a cure, no time limits, independent insurance pays for it

What is the best guiding principle on what to say to a dying patient?

Ask how much they know and how much they would like to know

What are some aspects of a "good death"?

-Happens in line with patient's values and preferences

-Independence & dignity

-Attends to needs of pt and family

-Aggressive relief of symptoms

What are the nurse's responsibilities in postmortem care?

1) Place ID tags on body

2) Ensure death certificate is signed

3) Review organ donation arrangements

4) Place body in normal anatomic position & remove tubes (unless autopsy needed)

5) Secure personal items

6) Allow time for family to be alone with body

7) Attend to family's needs

What are the 5 rights of delegation?

Right task

Right circumstance

Right person

Right directions

Right evaluation

What are some characteristics of a good nurse leader?

Intuitive

Decisive

Self-confident

Good listener

Trustworthy

Empathetic

What is an explicit versus implicit leader?

Explicit = hired or appointed to position

Implicit = not appointed, just senior/smart

Autocratic Leader

Authoritarian, dictator, less room for creativity

Good in emergencies

Democratic Leader

Cooperation and input from group encouraged

Quantum Leader

Entire team is interconnected, change is good

Transactional Leader

Trade incentives to get tasks done

Transformational Leader

Motivates members to take risks to make change

Magnet Recognition Program

Recognize organizations that achieve excellence in nursing practice through better patient outcomes, shorter hospital stays, higher patient satisfaction, etc.

Requires transformational leaders

Values self-governance and autonomy

What are the required criteria for a task to be delegated?

-Task performed according to step sequence

-Predictable outcome

-Little modification from one situation to another

-No ongoing assessments or decision making needed

-Does not endanger patient

Can the nursing process be delegated?

No

What are some tasks that CAN be delegated to a UAP?

-Vitals

-CPR

-I/Os

-Patient transfer

-Ambulation

-Simple dressing changes

-Specimen collection

-Feeding

-Bathing

Can patient education be delegated to a UAP?

NO

Can CPR be delegated to a UAP?

Yes

Can I/Os be delegated to a UAP?

Yes

Can IV line care be delegated to a UAP?

NO

What are some things that should NOT be delegated to a UAP?

-Assessments

-Nursing diagnoses / care plans

-Invasive line care

-Evaluating treatment effectiveness

-Med admin

-Inserting NG tubes

-Patient education

Can feeding be delegated to a CNA?

Yes

What are some tasks that can be delegated to an LPN?

Giving meds (ONLY ORAL)

Foleys

Chronic trach care/suctioning

Wound care

Enteral feedings

Monitoring patients

Can IV med administration be delegated to an LPN?

NO

Can enteral feedings be delegated to an LPN?

Yes

Can foley catheter insertion be delegated to an LPN?

Yes

Culture

A shared set of beliefs, values, and behavior that provides a social structure influenced by BIRTHPLACE and FAMILY ORIGIN

What are some examples of subcultures?

Nurses, bikers, transgender

Ethnicity

The sense of identity within a collective cultural group based on a common heritage (cultural patterns, adoption, birth)

Assimilation

Majority culture absorbs a minority culture, and the minority culture gradually loses its mark of identity

Ex: Muslim woman in America

Acculturation

Adopting the cultural patterns of a majority culture while continuing to maintain recognizable cultural markers

What are the requirements for language interpretors?

1. Give written & verbal info

2. Easy to read and understand

3. Interpreter must be competent

4. Must be trained

True/False: The patient may dictate how their food is prepared based on spiritual beliefs.

True

Spiritual Distress

Loss of hope and meaning of life through disturbance in belief or value system

"I feel no connection with God"

What is the best position for enema administration?

Left lateral

What is the safest type of enema to use?

Isotonic (normal saline)

Who does Healthy People 2020 intend to improve health for?

All Americans

Primary Health Promotion

Preventing illness and promoting health

-Vaccines

-Family planning

-Poison control information

-Weight loss education

-Accident prevention education

Secondary Health Promotion

Screening early for detection of diseases

-Annual exams

-Mammograms

-Teaching self breast exams

-Blood pressure screenings

Tertiary Health Promotion

Begins after illness is diagnosed to reduce disability and rehab the patient

-Medications

-Surgery

-Physical therapy

-ROM exercises

-Blood glucose tests

What are some ways to avoid CAUTIs?

Aseptic technique

Remove ASAP

Daily perineal care

Sealed, sterile drainage system

Use leg strap to secure tube

What type of catheter is needed for continuous irrigation?

3 way valve catheter

How much water per day is ideal?

8-10 8oz glasses of water per day

How much is a normal voiding pattern for urination per day?

5-6 times per day

Oliguria is defined as less than _________mL of urine produced per day.

400 mL

A normal adult should produce _____mL per hour.

30mL per hour

Transient urinary incontinence

Arrives suddenly, lasts less than 6 mo, causes are reversible

Ex: caused by infection or constipation

Established urinary incontinence

Chronic or persistent

Ex: stress incontinence

True/False: You need a Dr's order to do a bladder scan.

False! No order needed

If someone has an ileal conduit, are they continent or incontinent?

Incontinent

What are some continent urinary diversions?

Knock & indiana pouch

Neobladder

Dusky Stoma

Blue/purple stoma -> lack of oxygen causing dead tissue -> Alert provider immediately

Why is it important to verify patient's last meal/NPO status in pre-op before surgery?

Risk for vomiting and aspiration

True/False: It is out of the nurse's scope of practice to get informed consent from a patient before surgery.

True

What type of temperature alteration are surgical patients most at risk for?

Hypothermia

True/False: If a patient has purulent drainage immediately post-op, the nurse should change the dressing.

False!! After surgery, the nurse should not change the dressing. Must be done by doctor or ordered by doctor

Do not use an extremity for a blood pressure reading if it has...

IV

PICC line

Hx of mastectomy on that side

Dialysis catheter

True/False: Capillary blood glucose monitoring requires a doctor's order.

True

When can an alcohol-based hand sanitizer be used instead of hand washing?

If hands are NOT visibly soiled

Med orders should contain...

Drug

Dose

Route

Frequency

Date/Time of order

Prescriber signature

Patient's name

10 rights of med administration

Right drug

Right dose

Right time

Right route

Right patient

Right assessment

Right evaluation

Right documentation

Right to refuse

Right education

When should medication administration be documented?

Immediately

What angle is the needle inserted for subcutaneous injections?

45 degrees

What angle is the needle inserted for intradermal injections?

15 degrees

What are the 4 nursing QSEN competencies?

1) Patient-centered care

2) Teamwork

3) Evidence based practice

4) Informatics

What is a common developmental hazard for adolescents?

Car accidents, drug use, STDs, suicide, homicide

What is a common hazard for infants?

Stuffed animals in bed -> suffocation

What are some safety precautions that need to be taken for a patient with seizure disorder?

Pad bed rails

Have oxygen and suction at bedside

What is a leading cause of death in adolescents?

Suicide & homicide

What is the first step in preventing falls?

Assess fall risk

True/False: Restraints can be used to prevent falls.

FALSE! Restraints do not prevent falls

How often must the nurse document if restraints are being used?

Hourly

What are some rules in using restraints on a patient?

Document hourly

Requires provider order

Family must be informed

ONLY attach restraint to bed frame NOT rails

Use least restrictive restraint when possible

If side rails are used, patient must be able to raise and lower it themselves